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Published online before print September 16, 2005, 10.1148/radiol.2372040962
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(Radiology 2005;237:458-464.)
© RSNA, 2005

Cardiac Imaging

Contrast-enhanced MR Imaging for Evaluation of Coronary Artery Disease before Elective Repair of Aortic Aneurysm1

Masaki Ishida, MD, Hajime Sakuma, MD, Noriyuki Kato, MD, Nanaka Ishida, MD, Kakuya Kitagawa, MD, Takatsugu Shimono, MD, Isao Yada, MD and Kan Takeda, MD

1 From the Departments of Radiology (M.I., H.S., N.K., N.I., K.K., K.T.) and Thoracic and Cardiovascular Surgery (T.S., I.Y.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan. From the 2003 RSNA Annual Meeting. Received June 1, 2004; revision requested August 19; revision received November 8; accepted December 4. Address correspondence to H.S. (e-mail: sakuma{at}clin.medic.mie-u.ac.jp).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To prospectively evaluate the accuracy of first-pass contrast material–enhanced magnetic resonance (MR) imaging during stress and delayed contrast-enhanced MR imaging in the detection of significant coronary artery disease in patients before elective repair of aortic aneurysm.

MATERIALS AND METHODS: The study was approved by the institutional ethics committee, and informed consent was obtained from all patients. MR imaging was performed in 49 patients (42 men and seven women; mean age, 72.2 years; age range, 58–85 years) before the elective repair of atherosclerotic aortic aneurysms. Thirty-two patients had an abdominal aneurysm, 12 had a thoracic aneurysm, and five had a thoracoabdominal aneurysm. First-pass contrast-enhanced MR images were obtained with short-axis sections encompassing the entire left ventricular myocardium in the resting state and during pharmacologic stress. Inversion-recovery-prepared delayed contrast-enhanced MR images were obtained with breath holding to evaluate for the presence of infarction. All patients underwent coronary angiography within 2 weeks of MR imaging, and these findings were used as the standard of reference. The diagnostic results of first-pass contrast-enhanced MR imaging, delayed contrast-enhanced MR imaging, and a combination of both MR imaging methods in the detection of significant coronary artery disease were expressed as sensitivity, specificity, and accuracy.

RESULTS: Coronary angiography depicted a clinically significant stenosis (>70% luminal diameter narrowing) in the coronary artery in 34 of the 49 patients (69%). First-pass contrast-enhanced MR imaging depicted stress-induced hypoenhancement in 27 of those 34 patients (79%). Delayed myocardial enhancement was observed in 17 of the 34 patients (50%). The overall sensitivity of rest-stress first-pass contrast-enhanced MR imaging and delayed contrast-enhanced MR imaging combined in the prediction of at least one coronary artery with significant stenosis was 88% (30 of 34 patients). The specificity and accuracy of MR imaging were 87% (13 of 15 patients) and 88% (43 of 49 patients), respectively.

CONCLUSION: Contrast-enhanced MR imaging had an accuracy of 88% in the detection of significant coronary artery disease in patients with aortic aneurysm.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Atherosclerosis in multiple vascular areas is a major problem in the care of patients with vascular diseases, including aortic aneurysm, because attention and primary care are often focused on the symptomatic vascular subsystem, whereas undiagnosed associated vascular disease can substantially increase morbidity and mortality (1). In previous studies with selective coronary angiography, clinically significant coronary artery disease was found in approximately 31%–53% of patients with aortic aneurysms (2–5). Many investigators have indicated the importance of screening for coronary artery disease or revascularization of the coronary artery before aortic aneurysm repair for early and late survival (1–7). Because the diagnostic value of noninvasive tests such as electrocardiography and rest echocardiography is limited in the detection of stenosis in the coronary artery, several authors recommend routine coronary angiography in all patients before surgical or endovascular repair of aortic diseases (2,5). The use of routine coronary angiography in all patients with aortic diseases, however, may increase unnecessary risk and costs.

Contrast material–enhanced magnetic resonance (MR) imaging of the heart is emerging as a noninvasive method that can allow comprehensive assessment of myocardial ischemia and infarction. Dynamic MR imaging after a bolus of MR contrast material during pharmacologic stress enables the noninvasive detection of myocardial ischemia caused by flow-limiting stenosis in the coronary artery (8–14). In addition, infarcted myocardium can be clearly visualized on delayed contrast-enhanced MR images (15–19). Thus, the purpose of this study was to prospectively evaluate the accuracy of first-pass contrast-enhanced MR imaging during stress and delayed contrast-enhanced MR imaging in the detection of clinically significant coronary artery disease before patients undergo elective repair of an aortic aneurysm. Coronary angiography was used as the reference standard.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Patients
In this prospective study, 49 patients with aortic aneurysm who met the following inclusion and exclusion criteria were enrolled from June 1999 to January 2003. Thirty-two patients had an abdominal aneurysm, 12 had a thoracic aneurysm, and five had a thoracoabdominal aneurysm. There were 42 men and seven women aged 58–85 years (mean age ± standard deviation, 72.2 years ± 6.9). Patients were included in the study if (a) an atherosclerotic aortic aneurysm was previously detected at computed tomography (CT) and the patient was scheduled to undergo elective repair of the aortic aneurysm and (b) there was no contraindication for contrast-enhanced MR imaging with stress and coronary angiography. Patients with nonatherosclerotic aortic aneurysm (eg, traumatic, mycotic, anastomotic, and dissection related) and those who had previously undergone coronary revascularization procedures were excluded. Our study protocol was approved by the institutional ethics committee, and informed consent was obtained from all patients. Both contrast-enhanced MR imaging and catheter coronary angiography were performed less than 2 weeks before repair of the aortic aneurysm. Diagnostic MR images and coronary angiograms were successfully obtained in all patients.

Coronary Angiography and Interpretation
Coronary angiography (the reference standard) was performed in all patients by using a biplanar angiography system (Advantx ACT BP; GE Medical Systems, Waukesha, Wis) and 5-F Judkins or Amplatz catheters (Clinical Supply, Gifu, Japan). Five cardiologists were involved in performing coronary angiography. One cardiologist with 16 years of experience performed a quantitative analysis to determine the severity of coronary artery stenosis by using a workstation (Advantage CRS and QCA package; GE Medical Systems) and without knowing the results of the MR imaging study. To evaluate the sensitivity and specificity of rest-stress first-pass contrast-enhanced MR imaging in the detection of myocardial ischemia caused by flow-limiting stenosis, a luminal diameter narrowing of at least 70% at coronary angiography was considered to be clinically significant.

MR Imaging Protocol
MR images were obtained with a 1.5-T unit (Signa CV/i; GE Medical Systems) equipped with high-performance gradients for cardiac MR imaging (maximum slew rate, 150 T/m/sec; gradient strength, 40 mT/m) and a four-element phased-array coil. First-pass contrast-enhanced MR images were obtained in the resting state and during pharmacologic stress with an electrocardiographically gated gradient-echo sequence by using fast echo-planar readouts and interleaved notched saturation with the following parameters: 6.7/1.4/180.0 (repetition time msec/echo time msec/inversion time msec); 20° flip angle; echo train length, four; receiver bandwidth, ±125 kHz; 32–38-cm field of view; 128 x 128 matrix; 10-mm-thick sections; 2-mm intersection gap; true pixel size, 2.5 x 2.5 mm (10). Seven to eight short-axis images of the left ventricle were obtained for every other heartbeat for approximately 1 minute. As soon as dynamic image acquisition started, 0.075 mmol/kg gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) was injected into the antecubital vein at a rate of 4 mL/sec followed by a 20-mL saline flush. The patients were instructed to begin holding their breath at the start of image acquisition and to maintain the breath hold as long as possible. Approximately 10 minutes after the acquisition of first-pass contrast-enhanced MR images in the resting state, the patients received an intravenous injection of 0.56 mg/kg dipyridamole (Persantin Injection; Boehringer Ingelheim, Ingelheim, Germany) for 4 minutes. Then, first-pass contrast-enhanced MR images during stress were obtained by using the same imaging parameters and dose of gadopentetate dimeglumine as used previously. One author (N.I.) continuously monitored blood pressure, heart rate, and any serious adverse reactions caused by the pharmacologic stress throughout the MR examination (BP-203i; Nippon Colin, Komaki, Japan).

To evaluate the presence of myocardial infarction, electrocardiographically gated delayed contrast-enhanced MR images were obtained during breath holding 15 minutes after stress first-pass contrast-enhanced MR imaging with a cumulative dose of 0.15 mmol/kg gadopentetate dimeglumine (20–24). Inversion-recovery prepared fast gradient-echo MR images were obtained in contiguous short-axis imaging planes and long-axis imaging planes of the left ventricle with the following parameters: 5.6/1.7 (repetition time msec/echo time msec); 20° flip angle; receiver bandwidth, ±31.25 kHz; 32–38-cm field of view; 256 x 160 matrix; 10-mm-thick sections. A non–section-selective inversion-recovery pulse was used to maximize the contrast between infarcted and normal myocardium. Inversion time was adjusted in each patient to minimize the signal intensity of normal myocardium. To find an optimal inversion time, test images were obtained by using at least three different inversion time values. The acquisition of delayed-enhanced MR images necessitates approximately 5 minutes. The total MR study time was approximately 50 minutes. The quality of MR images was considered to be adequate when the presence or absence of hypoperfusion could be assessed visually in all segments of the left ventricle. The first-pass contrast-enhanced MR images obtained at rest and during stress and the inversion-recovery prepared delayed-enhanced MR images were of adequate quality for diagnosis in all patients. The mean blood pressure and heart rate (±standard deviation) were 96.0 mm Hg ± 13.0 and 70.2 beats per minute ± 15.8, respectively, before stress and 85.8 mm Hg ± 13.6 and 81.5 beats per minute ± 16.3, respectively, during stress. The mean total volume of injected gadopentetate dimeglumine was 16.8 mL ± 3.4.

Assessment of MR Images
Delayed contrast-enhanced MR images and first-pass contrast-enhanced MR images were qualitatively evaluated by consensus of two radiologists (H.S., N.I.) with 15 and 7 years of experience, respectively, in cardiac MR imaging. Images of the left ventricular myocardium were divided into three territories that corresponded to the locations of the three major coronary arteries, as follows: left anterior descending artery, circumflex artery, and right coronary artery (25). To evaluate myocardial infarction, two readers blinded to the results of coronary angiography recorded the presence or absence of delayed hyperenhancement on contrast-enhanced MR images by consensus. Delayed hyperenhancement on inversion-recovery prepared MR images was categorized into transmural hyperenhancement (>51% transmural extent of the left ventricular wall) or subendocardial hyperenhancement (<50% transmural extent of the left ventricular wall) by visually assessing the transmural extent of hyperenhanced tissue.

To evaluate myocardial ischemia caused by flow-limiting stenosis in the coronary artery, the two readers, in consensus and blinded to the results of coronary angiography, recorded the presence or absence of hypoperfusion induced by stress by visually evaluating the first-pass transit of gadopentetate dimeglumine through the myocardium. Both rest and stress first-pass contrast-enhanced MR images were displayed side by side on a workstation. First-pass contrast-enhanced MR images were evaluated by manually paging the images. A perfusion defect on the MR images was defined as a focal region of myocardium that had diminished contrast enhancement compared with normal myocardium on first-pass contrast-enhanced MR images (26). Stenotic coronary artery disease was considered to be present if there was a hypoperfusion during stress that was not observed at rest in an area that did not exhibit abnormal enhancement on delayed-enhanced MR images (Table 1). If similar hypoenhancement was observed both at rest and during stress, it was considered to be an artifact or infarction, and absence of stress-induced hypoperfusion was recorded. The presence or absence of myocardial infarction was determined by using delayed contrast-enhanced MR images. In the myocardial segments exhibiting hyperenhancement on delayed contrast-enhanced MR images, the presence and absence of hypoperfusion induced by stress were evaluated in noninfarcted myocardium adjacent to the area of infarction.


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  		TABLE 1. Criteria Used for Visual Interpretation of Rest and Stress First-Pass Contrast-enhanced MR Images

 
The relationship between results of contrast-enhanced MR imaging and the therapeutic courses in the patients scheduled for repair of an aortic aneurysm was determined by examining whether the patients underwent coronary revascularization or surgical repair of the aortic aneurysm.

Statistical Analysis
All values were expressed as mean ± standard deviation. All measurements were noted on an electric data sheet (Excel 2003; Microsoft, Redmond, Wash). The diagnostic results of stress first-pass contrast-enhanced MR imaging, delayed contrast-enhanced MR imaging, and a combination of both methods in patients with at least one coronary artery with significant stenosis were expressed as sensitivity, specificity, and accuracy with the corresponding 95% confidence intervals.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Coronary Angiography
At selective coronary angiography, a stenosis of at least 70% of the coronary artery diameter was observed in 34 of the 49 patients (69%). Fifteen of the 34 patients (44%) had single-vessel disease, 10 (29%) had double-vessel disease, and nine (26%) had triple-vessel disease.

MR Imaging
Of the 34 patients with significant coronary artery stenosis, 27 (79%) had stress-induced hypoperfusion on first-pass contrast-enhanced MR images (Fig 1). Delayed hyperenhancement was observed on contrast-enhanced MR images in 17 of the 34 patients (50%) with coronary artery disease (Fig 2). In three of these 17 patients, a perfusion abnormality was not depicted at first-pass contrast-enhanced MR imaging during stress. Table 2 summarizes the presence of transmural and subendocardial hyperenhancement on delayed contrast-enhanced MR images in myocardial segments with and without significant coronary artery disease. Occlusion of the coronary artery was observed in seven of eight segments (88%) with transmural hyperenhancement. Although the sensitivity of delayed contrast-enhanced MR imaging alone was limited, the excellent sensitivity was achieved by combining stress first-pass contrast-enhanced MR imaging and delayed contrast-enhanced MR imaging (Tables 3, 4). The sensitivity, specificity, and diagnostic accuracy of both modalities combined in the detection of significant stenosis in at least one coronary artery was 88% (30 of 34 patients), 87% (13 of 15 patients), and 88% (43 of 49 patients), respectively (Table 3). When MR images were analyzed on the basis of individual vascular territory, the sensitivities of first-pass contrast-enhanced MR imaging and delayed contrast-enhanced MR imaging in the identification of significant coronary artery stenosis were 73% (43 of 59 arteries) and 29% (17 of 59 arteries), respectively. The sensitivity, specificity, and diagnostic accuracy of the combined contrast-enhanced MR imaging techniques for depicting significant stenosis in the individual coronary arteries were 78% (46 of 59 arteries), 86% (76 of 88 arteries), and 82% (120 of 147 arteries), respectively (Table 4).



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  		Figure 1. Images obtained in a 58-year-old man with an abdominal aortic aneurysm. A, Abdominal aortogram (anterior view) demonstrates the abdominal aortic aneurysm (arrow). Left anterior oblique coronary angiograms demonstrate right coronary artery occlusion with collateral vessels (arrow). Significant stenosis and total occlusion with collateral vessels were observed in the left circumflex artery (arrowheads). First-pass contrast-enhanced MR images (6.7/1.4/180) obtained, D, in the resting state and, E, during stress through the short-axis plane of the left ventricle show myocardial hypoperfusion in the inferior and posterolateral walls of the left ventricle (arrows). The motion of the left ventricular wall was normal, and no infarcted myocardium was observed on delayed-enhanced MR images (not shown).

 


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  		Figure 2. Images in a 70-year-old man with an abdominal aortic aneurysm. A, Abdominal aortogram demonstrates the abdominal aortic aneurysm (arrow). Coronary angiograms obtained with, B, left and, C, right anterior oblique views demonstrate significant stenoses in the right coronary artery and left anterior descending artery (black arrows). Total occlusion with collateral vessels was observed in the left circumflex artery (white arrow). D, First-pass contrast-enhanced MR image (6.7/1.4; saturation recovery time, 180 msec) obtained during stress through the short-axis plane of the left ventricle reveals decreased perfusion in the posterolateral and inferior walls and the inferior part of the septum (arrowheads). E, Delayed contrast-enhanced MR image obtained with a segmented inversion-recovery fast low-angle shot sequence (5.6/1.7; saturation recovery time, 250 msec) through the short-axis plane of the left ventricle demonstrates a subendocardial infarction (arrowheads) in the posterolateral wall of the left ventricle.

 

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  		TABLE 2. Presence or Absence of Myocardial Hyperenhancement on Delayed Contrast-enhanced MR Images in Myocardial Segments Perfused by the Coronary Arteries with and without Significant Coronary Artery Disease

 

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  		TABLE 3. Sensitivity and Specificity of Stress First-Pass Contrast-enhanced MR Imaging and Delayed Contrast-enhanced MR Imaging in the Detection of Patients with Significant Coronary Artery Disease in At Least One Coronary Artery

 

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  		TABLE 4. Sensitivity and Specificity of Stress First-Pass Contrast-enhanced MR Imaging and Delayed Contrast-enhanced MR Imaging for Depicting Significant Stenosis in Individual Coronary Arteries

 
Table 5 summarizes the relationship between the results of contrast-enhanced MR imaging and therapeutic courses in the patients scheduled for repair of aortic aneurysm. Coronary revascularization was performed before elective repair of the aortic aneurysm in 12 patients because there was significant luminal narrowing in the major coronary arteries with residual viable myocardium in the corresponding segments. Contrast-enhanced MR imaging did depict significant coronary artery disease in 11 of these 12 patients (92%).


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  		TABLE 5. Relationship between Findings at Contrast-enhanced MR Imaging and Therapeutic Course in Patients Scheduled to undergo Repair of an Aortic Aneurysm

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
In the present study, the diagnostic value of first-pass contrast-enhanced MR imaging during stress and delayed contrast-enhanced MR imaging in the detection of coronary artery disease were evaluated in patients before they underwent surgical and endovascular repair of the aorta. In contrast to previous studies (13,14), patients with previous myocardial infarction were not excluded from this study. The overall sensitivity of comprehensive contrast-enhanced MR imaging in the prediction of significant coronary artery disease with coronary angiography was 88% (30 of 34 patients), which indicates the usefulness of MR imaging in the detection of concomitant coronary artery disease in patients with aortic aneurysms.

Frequency and Prognostic Importance of Coronary Artery Disease in Patients with Aortic Disease
Because of the poor natural history of large aortic aneurysms without repair (27,28), elective surgical or endovascular repair is indicated in all patients with aortic aneurysms, except those who are extremely moribund. Because of improvements in perioperative management and surgical techniques, the 30-day mortality rate with surgical abdominal aortic aneurysm repair is very low (<5%) (29). However, the 5-year survival rate after abdominal aortic aneurysm repair is reported to be 65%–70% (30), and more than a third of long-term deaths after surgery are caused by coronary artery disease (7). Previous studies have found that the incidence of significant coronary artery disease in patients with aortic disease is extremely high (2–5). Consequently, many groups have been motivated to perform preoperative cardiac tests in all patients scheduled to undergo aortic aneurysm repair.

Methods for Screening Patients with Aortic Disease for Coronary Artery Disease
Although it is very important to evaluate coronary artery disease with an accurate imaging modality before patients undergo aortic repair, consensus is still lacking about imaging approaches for screening coronary artery disease in those patients. The most reliable and aggressive approach for detecting stenosis in the coronary artery is to perform coronary angiography in all patients. Selective coronary angiography has been used as the standard of reference for demonstrating luminal narrowing in the coronary artery.

Several noninvasive methods have been used to screen for coronary artery disease in patients with aortic aneurysms. Electrocardiography and the assessment of left ventricular wall motion with echocardiography are noninvasive and readily available. Although these methods can depict large transmural myocardial infarction, the diagnostic value of these approaches in the detection of flow-limiting stenoses in the coronary arteries and subendocardial myocardial infarction is limited. The use of exercise stress electrocardiography or stress echocardiography with a high dose of dobutamine can improve the diagnostic accuracy in the detection of coronary artery disease (31). Exercise stress and high doses of dobutamine, however, increase heart rates and cardiac output, which is usually contraindicated in patients with aortic aneurysms.

Single photon emission computed tomography (SPECT) and positron emission tomography (PET) have been used to evaluate myocardial perfusion (32–37). Results of a previous study (38) indicated that myocardial perfusion SPECT with pharmacologic stress is an effective approach in detecting significant coronary artery disease in patients with aortic disease. Rest or delayed myocardial perfusion SPECT can help delineate areas of infarcted myocardium, and stress myocardial perfusion SPECT is useful in assessing ischemic myocardium supplied by stenotic coronary arteries. The limitation of nuclear cardiology techniques is their dependency on radioactive tracers. In addition, SPECT is limited by attenuation artifacts, and PET is limited by its dependence on a cyclotron. In addition, subendocardial ischemia and infarction cannot be accurately detected with radionuclide methods (25).

Diagnostic Value of MR Imaging When Screening Patients with Aortic Disease for Coronary Artery Disease
Cardiac MR imaging has been used primarily to obtain anatomic information and evaluate left ventricular function. Myocardial perfusion abnormalities can be detected by using first-pass contrast-enhanced MR imaging during pharmacologic stress after the injection of a bolus of MR contrast material (11). With recent advances in fast cardiac MR imaging techniques, the diagnostic capability of first-pass contrast-enhanced MR imaging during pharmacologic stress has been substantially improved (39,40). Schwitter et al (12) reported that multisection MR imaging assessment of myocardial perfusion by using a hybrid echo-planar method has a sensitivity of 91% in the detection of coronary artery disease, as defined by a perfusion abnormality at nitrogen 13 ammonia PET. Recently, Ishida et al (13) reported that stress enhancement at dynamic MR imaging correlates more closely with quantitative coronary angiography results than does stress enhancement at SPECT.

Contrast-enhanced MR imaging has been used to visualize myocardial infarction for more than 15 years (15–19). The introduction of inversion-recovery breath-hold MR sequences has substantially improved the delineation of infarcted myocardium on contrast-enhanced MR images, permitting the detection of small subendocardial infarctions and old myocardial infarctions (25). Wagner et al (24) reported that contrast-enhanced MR imaging systematically depicted a subendocardial infarction that had been missed at SPECT, whereas SPECT and contrast-enhanced MR imaging depicted transmural myocardial infarcts at similar rates. In the current study, infarcted myocardium was observed on delayed contrast-enhanced MR images in 17 of the 34 patients with coronary artery disease. In three of these 17 patients, a perfusion abnormality was not depicted at first-pass contrast-enhanced MR imaging during stress. The combined use of first-pass contrast-enhanced MR imaging during stress and delayed contrast-enhanced MR imaging resulted in an improved sensitivity (88%) for predicting coronary artery disease in patients before surgical or endoluminal repair of the aortic aneurysm.

In the current study population, 12 patients underwent a coronary revascularization procedure before undergoing elective repair of an aortic aneurysm. The indication for coronary revascularization was determined by using multiple factors, including the severity and location of the coronary artery stenosis, the presence or absence of viable myocardium in the corresponding myocardial segments, and the patient's symptoms and general condition.

Limitations
Several study limitations should be acknowledged. The number of patients was relatively small. Because of the high frequency of coronary artery disease in the current study population, an accurate determination of the specificity of MR imaging was difficult. In previous studies (12,13), first-pass contrast-enhanced MR imaging with stress showed a high specificity (85%–94%) in the prediction of significant coronary artery disease. In our current study, neither quantitative nor semiquantitative assessment of first-pass contrast-enhanced MR imaging was performed. Quantitative assessment of first-pass contrast-enhanced MR imaging with correction for inhomogeneous coil sensitivity may further improve the sensitivity and specificity of first-pass contrast-enhanced MR imaging and may be useful for eliminating interobserver variabilities. In one patient who underwent revascularization for a significant coronary arterial narrowing demonstrated at coronary angiography, no myocardial ischemia or infarction was observed at contrast-enhanced MR imaging. Coronary artery disease involves a continuous spectrum of stenosis, and angiographic approaches do not enable precise evaluation of the physiologic influences that coronary artery stenoses have on coronary artery blood flow. Some stenoses that are physiologically insignificant may be classified as significant disease, and some physiologically significant stenoses may be classified as insignificant disease when coronary angiography is used as the reference standard.

Conclusion
The frequency of significant coronary artery disease in patients with aortic disease is high in previous studies and in the current study. Because many patients with significant coronary disease are asymptomatic, noninvasive screening of coronary artery disease in patients with aortic disease is important for improving the prognosis. Contrast-enhanced MR imaging of the heart can provide comprehensive assessments of myocardial ischemia and myocardial infarction. With the overall 88% sensitivity observed in this study, contrast-enhanced cardiac MR imaging may be an alternative to invasive coronary angiography in the detection of coexisting coronary artery disease in patients before they undergo repair of the aorta.


   FOOTNOTES
 
Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, M.I., H.S.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, M.I., H.S.; clinical studies, all authors; and manuscript editing, M.I., H.S.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Fusari M, Parolari A, Agostinelli A, et al. Coronary and major vascular disease: aggressive screening and priority-based therapy. Cardiovasc Surg 2000;8:22–30.[CrossRef][Medline]
  2. Hertzer NR, Young JR, Kramer JR, et al. Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascuralization in patients with peripheral vascular disease. Arch Surg 1979;114:1336–1344.[Abstract/Free Full Text]
  3. Hertzer NR, Beven EG, Young JR, et al. Cononary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and result of surgical management. Ann Surg 1984;199:223–233.[Medline]
  4. Arpesani A, Giorgetti PL, Rampoldi V, Bordoni MG, Anguissola GB, Tealdi D. Cardiological risk in patients undergoing abdominal aortic aneurysm surgery, an analysis of 523 cases. Panminerva Med 1991;33:11–16.[Medline]
  5. Bayazit M, Gol MK, Battaloglu B, Tokmakoglu H, Tasdemir O, Bayazit K. Routine coronary arteriography before abdominal aortic aneurysm repair. Am J Surg 1995;170:246–250.[CrossRef][Medline]
  6. Weisel RD. Preoperative management of the patient with coronary artery disease before abdominal aortic surgery. Can J Surg 1987;30:237–239.[Medline]
  7. Hollier LH, Plate G, O'Brien PC, et al. Late survival after abdominal aortic aneurysm repair: influence of coronary artery disease. J Vasc Surg 1984;1:290–299.[CrossRef][Medline]
  8. Nagel E, Al-Saadi N, Fleck E. Cardiovascular magnetic resonance: myocardial perfusion. Herz 2000;25:409–416.[CrossRef][Medline]
  9. Laddis T, Manning WJ, Danias PG. Cardiac MRI for assessment of myocardial perfusion: current status and future perspectives. J Nucl Cardiol 2001;8:207–214.[CrossRef][Medline]
  10. Slavin GS, Wolff SD, Gupta SN, Foo TK. First-pass myocardial perfusion MR imaging with interleaved notched saturation: feasibility study. Radiology 2001;219:258–263.[Abstract/Free Full Text]
  11. Panting JR, Gatehouse PD, Yang GZ, et al. Echo-planar magnetic resonance myocardial perfusion imaging: parametric map analysis and comparison with thallium SPECT. J Magn Reson Imaging 2001;13:192–200.[CrossRef][Medline]
  12. Schwitter J, Nanz D, Kneifel S, et al. Assessment of myocardial perfusion in coronary artery disease by magnetic resonance: a comparison with positron emission tomography and coronary angiography. Circulation 2001;103:2230–2235.[Abstract/Free Full Text]
  13. Ishida N, Sakuma H, Motoyasu M, et al. Noninfarcted myocardium: correlation between dynamic first-pass contrast-enhanced myocardial MR imaging and quantitative coronary angiography. Radiology 2003;229:209–216.[Abstract/Free Full Text]
  14. Nagel E, Klein C, Paetsch I, et al. Magnetic resonance perfusion measurements for the noninvasive detection of coronary artery disease. Circulation 2003;108:432–437.[Abstract/Free Full Text]
  15. Tscholakoff D, Higgins CB, Sechtem U, McNamara MT. Occlusive and reperfused myocardial infarcts: effect of Gd-DTPA on ECG-gated MR imaging. Radiology 1986;160:515–519.[Abstract/Free Full Text]
  16. de Roos A, Doornbos J, van der Wall EE, van Voorthuisen AE. MR imaging of acute myocardial infarction: value of Gd-DTPA. AJR Am J Roentgenol 1988;150:531–534.
  17. Sandstede JJ, Lipke C, Beer M, et al. Analysis of first-pass and delayed contrast-enhancement patterns of dysfunctional myocardium on MR imaging: use in the prediction of myocardial viability. AJR Am J Roentgenol 2000;174:1737–1740.[Abstract/Free Full Text]
  18. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;343:1445–1453.[Abstract/Free Full Text]
  19. Simonetti OP, Kim RJ, Fieno DS, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001;218:215–223.[Abstract/Free Full Text]
  20. Choi KM, Kim RJ, Gubernikoff G, Vargas JD, Parker M, Judd RM. Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation 2001;104:1101–1107.[Abstract/Free Full Text]
  21. Wu E, Judd RM, Vargas JD, Klocke FJ, Bonow RO, Kim RJ. Visualisation of presence, location, and transmural extent of healed Q- wave and non-Q-wave myocardial infarction. Lancet 2001;357:21–28.[CrossRef][Medline]
  22. Mahrholdt H, Wagner A, Holly TA, et al. Reproducibility of chronic infarct size measurement by contrast-enhanced magnetic resonance imaging. Circulation 2002;106:2322–2327.[Abstract/Free Full Text]
  23. Mahrholdt H, Wagner A, Parker M, et al. Relationship of contractile function to transmural extent of infarction in patients with chronic coronary artery disease. J Am Coll Cardiol 2003;42:505–512.[Abstract/Free Full Text]
  24. Wagner A, Mahrholdt H, Holly TA, et al. Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet 2003;361:374–379.[CrossRef][Medline]
  25. Lauerma K, Virtanen KS, Sipila LM, Hekali P, Aronen HJ. Multislice MRI in assessment of myocardial perfusion in patients with single-vessel proximal left anterior descending coronary artery disease before and after revascularization. Circulation 1997;96:2859–2867.[Abstract/Free Full Text]
  26. Wolff SD, Schwitter J, Coulden R, Friedrich MG, Bluemke DA. Myocardial first-pass perfusion magnetic resonance imaging: a multicenter dose-ranging study. Circulation 2004;110:732–737.[Abstract/Free Full Text]
  27. Estes JE. Abdominal aortic aneurysm: a study of one hundred and two cases. Circulation 1950;2:258–264.[Medline]
  28. Szilagyi DE, Smith RF, DeRusso FJ, Elliott JP, Sherrin FW. Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 1966;164:678–699.[Medline]
  29. Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328:1167–1172.[Free Full Text]
  30. Feinglass J, Pearce WH, Martine GJ. Prognosis after graft replacement operation for abdominal aortic aneurysm. West J Med 1993;159:474–480.[Medline]
  31. Sawada SG, Segar DS, Ryan T, et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation 1991;83:1605–1614.[Abstract/Free Full Text]
  32. Versaci F, Tomai F, Nudi F, et al. Differences of regional coronary flow reserve assessed by adenosine thallium-201 scintigraphy early and 6 months after successful percutaneous transluminal coronary angioplasty or stent implantation. Am J Cardiol 1996;78:1097–1102.[Medline]
  33. Walsh MN, Geltman EM, Steele RL, et al. Augmented myocardial perfusion reserve after coronary angioplasty quantified by positron emission tomography with H2(15)O. J Am Coll Cardiol 1990;15:119–127.[Abstract]
  34. Iskandrian AS, Lemlek J, Ogilby JD, Untereker WJ, Cave V, Heo J. Early thallium imaging after percutaneous transluminal coronary angioplasty: tomographic evaluation during adenosine-induced coronary hyperemia. J Nucl Med 1992;33:2086–2089.[Abstract/Free Full Text]
  35. Hecht HS, Shaw RE, Chin HL, Ryan C, Stertzer SH, Myler RK. Silent ischemia after coronary angioplasty: evaluation of restenosis and extent of ischemia in asymptomatic patients by tomographic thallium-201 exercise imaging and comparison with symptomatic patients. J Am Coll Cardiol 1991;17:670–677.[Abstract]
  36. Hardoff R, Shefer A, Gips S, et al. Predicting late restenosis after coronary angioplasty by very early (12 to 24 h) thallium-201 scintigraphy: implications with regard to mechanisms of late coronary restenosis. J Am Coll Cardiol 1990;15:1486–1492.[Abstract]
  37. Uren NG, Crake T, Lefroy DC, Silva RD, Davies GJ, Maseri A. Delayed recovery of coronary resistive vessel function after coronary angioplasty. J Am Coll Cardiol 1993;21:612–621.[Abstract]
  38. Quigley FG, Clark D, Avramovic J. Cardiac assessment with thallium scanning prior to aortic aneurysm repair. Cardiovasc Surg 1999;7:640–644.[CrossRef][Medline]
  39. Epstein FH, Arai AE. Optimization of fast cardiac imaging using an echo-train readout. J Magn Reson Imaging 2000;11:75–80.[CrossRef][Medline]
  40. Epstein FH, Wolff SD, Arai AE. Segmented k-space fast cardiac imaging using an echo-train readout. Magn Reson Med 1999;41:609–613.[CrossRef][Medline]



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T. Kurita, H. Sakuma, K. Onishi, M. Ishida, K. Kitagawa, T. Yamanaka, T. Tanigawa, T. Kitamura, K. Takeda, and M. Ito
Regional myocardial perfusion reserve determined using myocardial perfusion magnetic resonance imaging showed a direct correlation with coronary flow velocity reserve by Doppler flow wire
Eur. Heart J., February 2, 2009; 30(4): 444 - 452.
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